DESCRIPTION

SUBSTANCE NAME

SUBSTANCE CLASS

ACTIVE INGREDIENT

Recommended dose is 1 to 2 capsules, then another 1 to 2 after 2 hours. Maximum dose 3 capsules. Available in packets of 6 or 18.

Warning: Tablets claim to contain "500 mg". However, this refers to total mg of all ingredients, not active ingredients, and is effectively a meaningless statement.

USES

While piperazine-based hallucinogenics or stimulants are not currently used therapeutically, they are misused. It is believed to have a similar action as the hallucinogenic-amphetamines, explaining the reason for its abuse. It is less potent than methamphetamine or MDMA, but is being sold in continuously increasing doses, making the effects more consistent with these more potent drugs.[1]

INTERVENTION CRITERIA

Intervention Level

The correct identification of the substance is important. If the symptoms are inconsistent with those described in the literature, or the history is considered unreliable, other substances may need to be considered.

Acute

Child

Appropriate medical assessment and observation is recommended for:

- Any exposure to a piperazine based hallucinogenic stimulant

Adult

Appropriate medical assessment and observation is recommended:

- If > 400 mg of a piperazine-based hallucinogenic stimulant is ingested

- Symptomatic patients (other than mild)

- Exposures with intent to self-harm

Observation Period

Observation at Home

If the patient does not require medical observation they can be monitored at home for 4 hours in the care of a reliable observer.

Medical attention should be sought if ANY symptoms occur, including:

Euphoria

Confusion/agitation

Anxiety

Increased heart rate

Palpitations

Chest pain

Gastrointestinal upset

Fever

Tremor

Medical Observation

If medical observation is required the patient must be monitored for 4 hours following exposure for onset or worsening of symptoms.

If the patient is asymptomatic at the end of the observation period (there is no agitation or serotonergic signs, and pulse, BP, temperature are normal), and provided that appropriate assessment and investigations have been carried out, they may be:

Discharged into the care of a reliable observer, or

Referred for psychological assessment (if the overdose or exposure was intentional)

TREATMENT

TREATMENT SUMMARY

Piperazine based hallucinogenic stimulants are considered to possess an hallucinogenic-amphetamine-like effect.

in the majority of cases gastrointestinal decontamination is unlikely to be beneficial. There is no antidote for intoxication and no methods for enhancing elimination can be recommended.

The majority of presentations will recover with a period of observation, calming environment and, if required, administration of a benzodiazepine. Patients may become dehydrated and require significant volume replacement, however, it is imperative to recognize those suffering hyponatremia as administration of fluids may prove fatal. Serum sodium must be measured, and CT brain scan undertaken to exclude cerebral edema in those with CNS signs.

The severely toxic may suffer seizure or cardiovascular abnormality. Persistent seizures require treatment with a benzodiazepine or if refractory, a barbiturate. Chest pain may indicate an acute coronary syndrome (arteriospasm) which will likely settle if the patient is calmed with a benzodiazepine, nitrate, or in severe cases a vasodilator such as phentolamine. Hyperthermia should be immediately and actively managed, and the patient carefully monitored for further complications including rhabdomyolysis, DIC, and renal failure. Serotonin syndrome should be considered, especially in those using other serotonergic compounds either therapeutically or recreationally.[2]

EMERGENCY STABILIZATION

Ensure Adequate Cardiopulmonary Function

Airway

Ensure the airway is protected if compromised (intubation may be necessary).

Cardiovascular

Immediately establish secure intravenous access.

A range of acute cardiovascular emergencies may occur due to vasospasm or vascular rupture. Such events include hemorrhagic or ischemic stroke, cardiac dysrhythmia/arrest, and dissection of large vessels including the aorta.

A range of acute cardiovascular emergencies may occur due to vasospasm or vascular rupture. Such events include hemorrhagic or ischemic stroke, cardiac dysrhythmia/arrest, dissection of large vessels including the aorta.

Cardiac Arrest

Prolonged cardiac resuscitation following standard ACLS protocols is warranted as recovery with a good neurological outcome is reported in poisoned patients receiving CPR for periods of 3 to 5 hours.[6]

Seizure

Administer a benzodiazepine as first-line treatment to patients with seizure activity.[7]

Blood glucose concentration should be promptly determined. If the result indicates hypoglycemia, or is unobtainable, supplemental dextrose should be administered IV.

Emergency Monitoring

Respiratory rate

Heart rate

Blood pressure

State of hydration

12 lead ECG

Serum electrolytes - especially sodium

Blood glucose

Neurological status

DECONTAMINATION

Ingestion

Decontamination Not Recommended

Efficacy of gastrointestinal decontamination is questionable as these compounds are rapidly absorbed and the patient is likely a late presenter and less than co-operative. As the risks likely outweigh benefit, activated charcoal is not recommended.

ANTIDOTE(S)

There Are No Antidotes For This Substance

There is no specific antidote for the treatment of this poisoning. Treatment is based on symptomatic and supportive care.

SIGNS AND SYMPTOMS

The correct identification of the substance is important. If the symptoms are inconsistent with those described in the literature, or the history is considered unreliable, other substances may need to be considered.

In more severe cases, seizures, collapse, myoclonic jerking, and extrapyramidal features (choreoathetoid movements, dystonic reactions) may occur.[9] Serotonin syndrome has also been reported.[12] Hypertension can be severe.[9] If prolonged or severe, fever and excessive motor activity may lead to hyperthermia, metabolic acidosis, disseminated intravascular coagulation, and acute kidney injury.[13] Psychosis has been reported.[14] Given piperazine's mechanism of action, theoretical concerns are cardiac dysrhythmia, acute hepatitis/liver failure, and death.[15]

Routes of Exposure

Benzylpiperazine (BZP) liquid and dust is known to be corrosive. This may cause burns to the gastrointestinal tract if swallowed or to the eye or skin if these areas are contaminated. Piperazine based hallucinogenic stimulants are also smoked by some individuals and there is also the potential for effects similar to inhalation of a corrosive (or acid) gas to manifest.

Tablets are often dissolved and directly injected. Due to the bulk of these tablets being composed of non-water soluble agents such as talc there is a high rate of complications following granuloma formation and vascular obliteration.[5][4] While the lung is a particular target with resultant pulmonary hypertension/cor pulmonale, other organs can be affected. Infection following such abuse is also a concern.[3]

Onset/Duration of Symptoms

Onset of affect is usually delayed about 2 hours post-ingestion.[1][16] Effects generally persist for about 12 to 24 hours, but may occur for up to 72 hours following use.[9] There may be a role for monoamine depletion/withdrawal in prolonged toxicity.

Neurologic

If large amounts of amphetamine or amphetamine-like compounds are consumed over a long period of time, amphetamine psychosis can develop, which is similar to paranoid schizophrenia. The psychosis is manifested by hallucinations, delusions and paranoia. Symptoms usually disappear within a few weeks after drug use stops.

A range of sequelae have been noted following chronic human abuse including:

A lasting paranoid psychotic reaction may develop,[24] and behavior can become destructive and violent. While the majority of patients recover within 10 days, effects persist for more than 6 months in 10% of cases.[25][26][27] Single re-exposures may produce acute exacerbations even after long periods of abstinence.

Gastrointestinal

Ischemic colitis can occur following long-term use of amphetamines.[28]

Other

Diffuse hair loss has been associated with long-term amphetamine use.[29][30]

Amphetamine and amphetamine-like compounds have rarely produced aplastic anemia and a fatal pancytopenia after prolonged use.[31]

Infections such as hepatitis B and C and HIV are possible complications of intravenous use of amphetamine and amphetamine-like compounds.[31]

Withdrawal Syndrome

Acute withdrawal may precipitate severe depression and suicidal thoughts. Symptoms usually peak after 2 to 3 days and are seldom directly life-threatening.

Disclaimer

All information contained on this database is as accurate and up-to-date as our resources allow. Since the University of Otago, the New Zealand National Poisons Centre and Intergen cannot anticipate or control the conditions under which this information may be used, each user should view the information in the specific context of the intended application.

The University of Otago, the New Zealand National Poisons Centre and Intergen will not be responsible for damages of any nature resulting from use or reliance upon this information.